Physical and mental health status of staff working for people with intellectual disabilities in Taiwan: Measurement with the 36-Item Short-Form (SF-36) health survey
Jin-Ding Lin
a,*, Tzong-Nan Lee
a, Ching-Hui Loh
b, Chia-Feng Yen
c, Shang-Wei Hsu
d, Jia-Ling Wu
e, Chi-Chieh Tang
f, Lan-Ping Lin
c, Cordia M. Chu
g, Sheng-Ru Wu
haSchool of Public Health, National Defense Medical Center, Taipei, Taiwan
bDepartment of Community and Family Medicine, Tri-Service General Hospital, Taipei, Taiwan
cGraduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
dGraduate Institute of Healthcare Administration, Asia University, Taichung, Taiwan
eResearch Center for Intellectual Disabilities Taiwan, Chung-Hua Foundation for Persons with Intellectual Disabilities, Taipei County, Taiwan
fDepartment of Early Childhood Care & Education, Pingtung Education University, Pingtung, Taiwan
gCenter for Environment and Population Health, Griffith University, Brisbane, Australia
hNational Taichung Special School, Taichung City, Taiwan
A R T I C L E I N F O
Article history:
Received 11 July 2008
Received in revised form 26 July 2008 Accepted 9 August 2008
Keywords:
Health status Intellectual disability SF-36
Staff
A B S T R A C T
Little explicit attention has been given to the generic health profile of staff working for people with intellectual disability in institu- tions. This study aimed to provide a profile of physical and mental health of staff working in disability welfare institutions, and to examine the possible demographic and organizational factors that explain an association with their health. A cross-sectional ques- tionnaire survey was conducted to analyze 1243 staff (76% response rate) working in 24 institutions in Taiwan. The 36-Item Short-Form (SF-36) Taiwan version was used to measure their generic health status. The mean of Physical component scores (PCS) was slightly higher than Mental component scores (MCS) (50.83 vs. 45.12). With regard to each dimension among PCS, the mean score of Physical functioning (PF) was 57.14 (S.D. = 5.93), Role limitations-physical (RP) was 49.88 (S.D. = 9.69), Bodily pain (BP) was 52.14 (S.D. = 8.09) and General medical health (GH) was 51.50 (S.D. = 8.28). Among the
* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Min-Chun East Road, Section 6, Nei-Hu, Taipei 114, Taiwan. Tel.: +886 2 8792 3100#18447; fax: +886 2 8792 3147.
E-mail address:Jack.Lin1964@gmail.com(J.-D. Lin).
Contents lists available at ScienceDirect
Research in Developmental Disabilities
0891-4222/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2008.08.002
1. Introduction
Many studies have focused on the state of health and quality of life of family caregivers who look after people with disabilities (Brown, Anand, Fung, Isaacs, & Baum, 2003; Dyson, 1997; Jokinen &
Brown, 2005; Schalock et al., 2002; Schulz, 2000; Schulz & Beach, 1999; Schulz, O’Brien, Bookwala, &
Fleissner, 1995; Summers et al., 2005). People with disabilities are more prone than the general population to particular health problems (Lin et al., 2007, 2006; Loh et al., 2007), their caregivers experienced a high prevalence of depression, burden and psychological distress (Olsson & Hwang, 2001). These stressors are directly related to health status, presence of behavioral and memory problems of the disabled people they cared for (Pearlin, Mullan, Semole, & Skaff, 1990; Schofield, Murpphy, Herrman, & Sing, 1997; Schulz, 2000; Schulz et al., 1995; Seoud et al., 2007). Browne and Bramston (1998) found that families with a member with a disability reported significantly greater stress and as the stress increased the quality of life decreases.
Besides the informal caregivers in the families, institutional staffs are among the most important assets in the provision of services and account for the large expenditure to people with intellectual disabilities (Jenkins, Rose, & Lovell, 1997; Rice & Rosen, 1991). The literature on staffing issues and staff stress in particular is growing rapidly, probably because this is considered to be an important variable in determining staff performance (Rose, 1999). Much of these literatures to date have concentrated on examining the elements which can contribute to or ameliorate stress (Corrigan, 1993;
Hastings, 2002; Rose, 1993; Rose, Jones, & Fletcher, 1998; Stenfert-Kroese & Fleming, 1992), such as challenging behavior of people with intellectual disabilities as a significant source of work-related stress of staff working in intellectual disability services (Hastings, 2002; Mitchell & Hastings, 2001).
Consequently, staff stress has been found to be associated with intended turnover and absenteeism from the service organization (Hatton & Emerson, 1993; Rose, 1995; Razza, 1993) and has serious implications for staff well-being, for their clients and for services (Rose, 1995; Hastings, 2002).
Little explicit attention has been given to the generic health profile of staff working for people with intellectual disability in institutions. Staff in institution supports and services for people with intellectual disabilities should be targeted with respect to ameliorating their negative and strengthening their positive health status. Therefore, the aims of the present study was to provide a profile of physical and mental health of staff working in disability welfare institutions, and to examine the possible demographic and organizational factors that may explain an association with their health.
2. Method
This study employed a cross-sectional questionnaire survey ‘‘2006 National Survey on Health Status and Working Stress among Institutional Staff Working for People with Intellectual Disabilities in Taiwan’’. The studies entire population was composed of 7466 staff who was working in all 244
MCS, Vitality (VT) was 46.19 (S.D. = 6.71); Social functioning (SF) was 46.44 (S.D. = 7.58); Role limitations-emotional (RE) was 47.30 (S.D. = 11.89) and Mental health (MH) was 43.58 (S.D. = 8.81). We found the generic health of staff working for people with intellectual disabilities were significantly lower in PCS and MCS than the Taiwan general population. Influences of staff’s demographic and organiza- tional characteristics on their health were also analyzed in the content.This study highlights the authorities and service providers need to continue to develop their awareness and understanding of the experiences that their staff encounters in the organizations, so that they can receive resources to support their positive health in working for people with intellectual disabilities.
ß2008 Elsevier Ltd. All rights reserved.
registered intellectual disability institutions at the end of year 2005 in Taiwan (Ministry of the Interior, 2006). Participants were stratified by geographic area and selected systematically according to the proportion of the institutions in each area for the study. We mailed the consent letter to the institutions for the survey. The details of our sampling procedure are presented elsewhere (Lin et al., in press).
The survey materials included an invitational letter, the 36-Item Short-Form (SF-36) and a demographic and institutional characteristic questionnaire. Originally, the SF-36 is a short form measure of generic health status in the general population and it is designed for self-administration.
From the 36 items, eight health profiles are derived from summarized scores. Four health profiles cover Physical component scores (PCS), including Physical functioning (PF), Role limitations-physical (RP), Bodily pain (BP) and General medical health (GH). The other four profiles are Mental component scores (MCS), and include Vitality (VT), Social functioning (SF), Role limitations-emotional (RE), and Mental health (MH). All dimensions are independent of each other. Scores for all dimensions are expressed on a scale 0–100, where higher scores indicate better health and well-being (Ware, 1993). It has been translated into the Chinese language in Taiwan and the norms of the SF-36 Taiwan version which can serve as a valuable reference for future comparisons (Tseng, Lu, & Tsai, 2003). The authors have received the approval from professor Jui-Fen R. Lu, Department of Health Care Management, Chang Gung University, to use the SF-36 Taiwan version in this study.
Data were collected by a questionnaire that was completed through the mail by the institutional staff from 1 December 2005 to 28 February 2006. A total of 1629 protocols were distributed to staff among 24 institutions in Taiwan, 1243 valid questionnaires were returned, with a response rate of 76%. The data were entered into a database and analyzed using SPSS 11.0 software.
3. Results
3.1. Respondent characteristics
The characteristics of the staff in the sample, more female than male (81.1% vs. 18.9%) and their average age was 38.61 years. They worked 45 h per week and averaged 6.5 years of work experience in the institution. Most of the respondents were first-line staff, and nearly 60% finished college or university education. Thirty-four and eight tens percent of the staff were unmarried. In the previous employment experience, more than 80% of the respondents reported that the present job was his/her first job in their working career. In term of the in-job training, 78.6% felt it was adequately, 15.7% felt it was inadequate and 5.7% did not have in-job training (Lin et al., in press).
3.2. Distribution of physical and mental component scores
We used mean, minimum/maximum values and standard deviations to describe the general health status of staff working for people with intellectual disabilities. The mean scores of the PCS, MCS and each dimension are presented in Table 1. The mean of PCS was slightly higher than MCS (50.83 vs.
45.12). With regard to each dimension among PCS, the mean score of PF was 57.14 (S.D. = 5.93), RP was 49.88 (S.D. = 9.69), BP was 52.14 (S.D. = 8.09) and GH 51.50 (S.D. = 8.28). Among the MCS, VT was 46.19 (S.D. = 6.71); SF was 46.44 (S.D. = 7.58); RE was 47.30 (S.D. = 11.89) and MH was 43.58 (S.D. = 8.81).
Tables 2 and 3 showed the gender difference in physical and mental component scores. Men were statistical higher in PCS mean score than women (P = 0.001). However, the MCS mean score was not significantly different by gender.
3.3. Influence of staff’s characteristics on their health
A one-way ANOVA and t-test were used to compare the means separately for each characteristic.
In-job training experience and gender of the staff were found to affect the PCS, while education,
marital status, religious status and in-job training experience characteristics were found to affect the
MCS statistical significantly (Tables 4 and 5). In a further analysis of the relationship of staff
demographic characteristics and PCS/MCS in Scheffe’s post test, the results showed that that those staff expressed with no or adequately in-job training were more likely to report higher scores in PCS/
MCS than those people who felt inadequately in-job training. Male staff has higher scores on the PCS than females. The relationship between education and MCS, showed that the higher educational level the lower in MCS score. Married staff reported lower MCS scores than others. Staff who indicated they were Buddhists reported higher MCS scores than those who indicated no specific religion.
3.4. Relation between institutional characteristic and staff’s health
Institutional characteristics were used to analyze their relation to the staff’s health. We found the factor of institutional ownership effected the PCS (P = 0.001). Staff working in private institutions have higher PCS scores than staff in private institutions, while staff working in a medium or small size of institution tended to report better PCS than persons working in a large institution (P = 0.002). With regard to the past performance record of the institution, superior institutions performance did not effect PCS ratings (Table 6).
Table 1
The health profile of the respondents in SF-36
Component N Min. Max. Mean S.D.
PCS 1222 19.21 62.18 50.83 7.67
PF 1240 17.29 57.14 52.71 5.93
RP 1231 27.95 56.24 49.88 9.69
BP 1240 19.93 62.75 52.14 8.09
GH 1238 25.39 70.35 51.50 8.28
MCS 1224 7.98 65.86 45.12 10.73
VT 1231 26.54 61.66 46.19 6.71
SF 1236 19.14 57.14 46.44 7.58
RE 1232 23.74 55.34 47.30 11.89
MH 1239 11.82 64.07 43.58 8.81
Notes: Physical component scores (PCS); Physical functioning (PF); Role limitations-physical (RP); Bodily pain (BP); General medical health (GH); Mental component scores (MCS); Vitality (VT); Social functioning (SF); Role limitations-emotional (RE);
Mental health (MH).
Table 2
The health profile of the respondents in SF-36 by gender
Gender Component N Min. Max. Mean S.D.
Male PCS 232 23.96 61.01 52.39 7.41
PF 234 31.97 57.14 53.81 5.24
RP 232 27.95 56.24 50.66 9.63
BP 234 29.35 62.75 54.13 8.04
GH 234 31.23 59.32 46.37 6.27
MCS 232 9.29 63.65 45.96 10.46
VT 234 30.12 70.35 52.25 8.38
SF 234 19.14 57.14 47.51 7.60
RE 232 23.74 55.34 47.71 11.73
MH 234 14.09 64.07 43.72 9.09
Female PCS 986 19.21 62.18 50.48 7.69
PF 1001 17.29 57.14 52.45 6.06
RP 995 27.95 56.24 49.68 9.70
BP 1001 19.93 62.75 51.71 8.01
GH 992 26.54 61.66 46.20 6.79
MCS 987 7.98 65.86 44.95 10.76
VT 999 25.39 70.35 51.33 8.22
SF 997 19.14 57.14 46.19 7.56
RE 995 23.74 55.34 47.21 11.93
MH 1000 11.82 64.07 43.58 8.71
The institutional characteristics’ impact on the MCS showed in Table 7, those factors of ownership (private higher than public) and accreditation record (good or below higher than superior) of the institution had a significant effect on MCS (P < 0.001). The work setting also played a key role on MCS.
Staff working in northern Taiwan reported higher MCS scores than their southern or eastern counterparts (P = 0.017).
4. Discussion
This study was the first paper to examine generic health status of staff working in disability welfare institutions in Taiwan. With regard to health status measurement of the staff working for people with
Table 3The relationship between generic health and the gender (N = 1243)
Component N Mean S.D. t-test P value
PCS 3.418 0.001
Male 232 52.39 7.41
Female 986 50.48 7.69
MCS 1.287 0.198
Male 232 45.96 10.46
Female 987 44.95 10.76
Table 4
Relationship of staff demographic characteristics and the PCS (N = 1243)
Characteristic N Means S.D. Statistics P value Scheffe’s post test
Job category 1.913(F) 0.148
1. Administration 148 51.42 7.37
2. First-line carers 872 50.50 7.79
3. Other 167 51.54 7.49
Education 0.363(F) 0.696
1. Junior high and below 141 51.03 7.26
2. Senior high school 346 51.12 7.43
3. College and up 724 50.72 7.81
Marital status 2.547(F) 0.079
1. Married 423 50.16 7.83
2. Unmarried 692 51.16 7.55
3. Other 91 51.40 7.68
Religious status 1.507(F) 0.198
1. Buddhism 374 50.91 7.80
2. Dao 237 51.31 7.54
3. Christian/Catholic 152 49.48 7.61
4. No specific 367 50.80 7.61
5. Other 55 51.44 7.73
Employment experience 1.383(F) 0.251
1. No, first job 987 987 50.92
2. Yes, same field 146 146 50.00
3. No, different field 74 74 51.70
In-job training 6.119(F) 0.002 1 > 3
1. No 68 53.00 6.05 2 > 3
2. Yes, adequate 938 50.97 7.64
3. Yes, inadequate 189 49.42 8.16
Gender 3.418(t) 0.001
Male 232 52.39 7.41
Female 986 50.48 7.69
Notes: F (ANOVA test); t (t-test).
intellectual disabilities, we used the SF-36 Health Survey to examine their health profile. Comparing the Taiwan national norms of SF-36 (Lin, 2003), we found the generic health of staff working for people with intellectual disabilities was significantly lower in PCS and MCS than the general population (P < 0.001) (Table 8). It was of not that these results were different from the US national norms of aged 55–64 years (Ware, Kosinski, & Keller, 1994). Our PCS mean scores were higher than the US mean data (45.0 11.6) and our MCS mean scores were lower than Ware et al. (50.6 10.2l). The possible reason might be age related. Our sample tended to be younger than their US counterparts.
Within the components of SF-36 in the study, most dimensions such as BP (P < 0.001), GH (P < 0.001), VT (P = 0.07), SF (P < 0.001) and MH (P < 0.001) were significant lower than the scores in Taiwan general population. The dimensions of RP and RE were not statistical different from the general population. However, there was only one dimension - RF in the study sample illustrated significantly higher than Taiwan general population (P < 0.001). Generic health status of staff working in disability institutions therefore appears to be threatened in. The health and social welfare authorities should consider initiating appropriate individual or corporate health promotion strategies to improve positive health for this group of people. With regard to the influence of personal characteristics on staffs’ health, gender significantly effected PCS. Our findings replicate Chen, Ryan-Henry, Heller, and Chen (2001), who found that personal factors such as marital status and education did not significantly influence caregiver’s health.
In-job training was correlated with PCS and MCS, particular for those who felt inadequate. These individuals were inclining to express poor health in physical or mental health mean scores. Thus, further investigations of appropriate in-job training in institutions are needed.
Table 5
Relationship of staff demographic characteristics and MCS (N = 1243)
Variable N Means S.D. Statistics* P value Scheffe’s post test
Job category 4.186(F) 0.027
1. Administration 147 46.69 9.90
2. First-line carers 872 44.47 10.99
3. Other 168 46.35 10.15
Education 21.335(F) <0.001 1 > 3
1. Junior high and below 142 48.97 9.46
2. Senior high school 348 46.84 10.11
3. College and up 721 43.62 10.97
Marital status 33.649(F) <0.001 2,3 > 1
1. Married 425 41.90 11.11
2. Unmarried 688 46.57 10.19
3. Other 93 49.17 9.51
Religious status 4.128(F) 0.003 1 > 4
1. Buddhism 370 46.06 10.54
2. Dao 241 45.67 10.65
3. Christian/Catholic 154 46.35 11.22
4. No specific 365 43.28 10.48
5. Other 55 45.45 11.13
Employment experience 0.035(F) 0.965
1. No, first job 988 45.14 10.82
2. Yes, same field 146 45.31 10.53
3. No, different field 73 44.90 10.59
In-job training 10.238 (F) <0.001 1 > 3
1. No 69 46.77 9.50 2 > 3
2. Yes, adequate 938 45.61 10.53
3. Yes, inadequate 188 41.91 11.92
Gender 1.287(t) 0.198
Male 232 45.96 10.46
Female 987 44.95 10.76
* Statistics: F (ANOVA test); t (t-test).
Other organizational characteristics such as ownership, setting location, accreditation perfor- mance and size played vital influences on staff’s health. This factor has not previously been assessed.
However, many studies have described institutional characteristics and were a moderating factor for staff health. The general organization of work and an individual’s position within the hierarchy effect staff’s stress (Allen, Pahl, & Quine, 1991; Elliott & Rose, 1997).
Hatton et al. (1999) found that around one-third of staff working in adult services experience stress at levels indicative of the presence of a mental health problem. The staff working in institutions often felt more anxious with the challenges behaviors of people with intellectual disabilities. Staff also reported feeling significantly less support and lower job satisfaction (Jenkins et al., 1997). The factor most often rated by staff as a significant source of stress was the challenging behaviors of people with intellectual disabilities (Bersani & Heifetz, 1985; Male & May, 1997; Rose et al., 1998). Rose, Horne, Rose, and Hastings (2004) analyzed staff’s emotional reactions to challenging behaviors experienced in caring for people with intellectual disabilities. Significant correlations were found between negative emotional reactions to challenging behavior and emotional exhaustion and depersonalization burnout. Therefore, the staff more frequently reported using adaptive strategies than maladaptive ones to cope with aggressive behavior of people with intellectual disabilities (Mitchell & Hastings, 2001).
Table 6
Relationship of institutional characteristics and PCS of the staff (N = 1243)
Characteristic N Means S.D. Statistics P value Scheffe’s post test
Setting location 2.400 (F) 0.091
1. North 377 51.17 7.08
2. Central 441 51.17 7.82
3. South and East 404 50.15 7.99
Ownership 3.212(t) 0.001
1. Public 509 49.98 8.36
2. Private 713 51.44 7.07
Accreditation 3.137(t) 0.002
1. Superior 427 49.82 8.26
2. Good and below 735 51.32 7.23
Setting sizea 2.399(t) 0. 017
1. Large 1056 50.66 7.86
2. Medium/Small 166 51.95 6.19
aSetting size presents the numbers of persons with ID in institution; large: 3100 persons, medium: 50–99 persons, small: <50 persons.
Table 7
Relationship of institutional characteristics and MCS of the staff (N = 1243)
Characteristic N Means S.D. Statistics P value Scheffe’s post test
Setting location 4.096(F) 0.017
1. North 377 46.36 10.62 1 > 3
2. Central 442 44.91 10.59
3. South and East 405 44.20 10.92
Ownership 4.083(t) <0.001
1. Public 509 43.62 11.26
2. Private 715 46.19 10.22
Accreditation 4.492(t) 0.264
1. Superior 426 43.15 11.20
2. Good and less 737 46.12 10.24
Setting sizea 1.117(t) <0.001
1. Large 1057 44.99 10.89
2. Medium/Small 167 45.98 9.69
aSetting size presents the numbers of persons with ID in institution; large: 3100 persons, medium: 50–99 persons, small: <50 persons.
Three main limitations need to be considered in interpreting the findings presented here. First, the SF-36 scale is too generic to pinpoint specific ill-health issue. Second, the possible influence of staff’s health—the demographic and organizational factors in this study are relatively one-dimensional and should be multidimensional across a number of aspects in the further study. Those dimension such as the caregiver’s health status, their family income and the level of severity of the intellectual disability maybe the strongest predictors of caregivers quality of life (Chou, Lin, Chang, & Schalock, 2007).
Finally, the cross-sectional nature of the study does not make it possible to ascertain the direction of the relationships. However, the study by accessing this available population that was willing to provide full information of physical and mental health, the researchers were able to provide some good preliminary data for the further quality of life research for staff working for people with disabilities. Finally, the study suggests that staff play a key role in the lives of people with intellectual disabilities and policies need to be developed that are responsive to the health needs of staff who working in institutions.
Acknowledgements
This research was in-part funded by the Chung-Hua Foundation for Persons with Intellectual Disabilities, Taipei County, Taiwan. We would also like to thank all the staff who took part in the study.
In addition, the authors want to acknowledge the kindness of professor Jui-Fen Rachel Lu, Department of Health Care Management, Chang Gung University, agreed to use the SF-36 Taiwan version in the study.
References
Allen, P., Pahl, J., & Quine, L. (1991). Care staff in transition: The impact on staff of changing services for people with mental handicaps.
London: HMSO.
Bersani, H. A., & Heifetz, L. J. (1985). Perceived stress and satisfaction of direct-care staff members in community residences for mentally retarded adults. American Journal of Mental Deficiency, 90, 289–295.
Brown, I., Anand, S., Fung, W. L., Isaacs, B., & Baum, N. (2003). Family quality of life: Canadian results from an international study.
Journal of Developmental and Physical Disabilities, 15, 207–230.
Browne, G., & Bramston, P. (1998). Stress and the quality of life in parents of young people with intellectual disabilities. Journal of Psychiatric and Mental Health Nursing, 5, 415–421.
Chen, S. C., Ryan-Henry, S., Heller, T., & Chen, E. H. (2001). Health status of mothers of adults with intellectual disability. Journal of Intellectual Disability Research, 45, 439–449.
Chou, Y. C., Lin, L. C., Chang, A. L., & Schalock, R. L. (2007). The quality of life of family caregivers of adults with intellectual disabilities in Taiwan. Journal of Applied Research in Intellectual Disabilities, 20, 200–210.
Corrigan, P. (1993). Staff stressors at a developmental centre and state hospital. Mental Retardation, 31, 234–238.
Dyson, L. L. (1997). Fathers and mothers of school-age children with developmental disabilities: Parental stress, family functioning, and social support. American Journal on Mental Retardation, 102, 267–279.
Elliott, J., & Rose, J. (1997). An investigation of stress experienced by managers of community homes for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 10, 48–53.
Table 8
Comparison of generic health status between this study and the Taiwan’s general population
Component This study Taiwan’s generala t-test P value
N Mean S.D. N Mean S.D.
PCS 1222 50.83 7.67 1303 52.53 6.90 7.736 <0.001
PF 1240 52.71 5.93 1342 51.95 6.15 4.533 <0.001
RP 1231 49.88 9.69 1349 49.63 9.57 0.897 0.37
BP 1240 52.14 8.09 1349 53.02 8.15 3.838 <0.001
GH 1238 51.50 8.28 1342 46.94 8.79 3.914 <0.001
MCS 1224 45.12 10.73 1303 46.39 6.95 4.130 <0.001
VT 1231 46.19 6.71 1346 52.13 7.95 2.716 0.007
SF 1236 46.44 7.58 1334 47.88 7.30 6.684 <0.001
RE 1232 47.30 11.89 1338 47.20 11.63 0.302 0.763
MH 1239 43.58 8.81 1346 45.13 8.84 6.178 <0.001
a Data source:Lin (2003).
Hastings, R. P. (2002). Do challenging behaviors affect staff psychological well-being? Issues of causality and mechanism. American Journal of Mental Retardation, 107, 455–467.
Hatton, C., & Emerson, E. (1993). Organizational predictors of staff stress, satisfaction and intended turnover in a service for multiple disabilities. Mental Retardation, 31, 388–395.
Hatton, C., Rivers, M., Emerson, E., Kiernan, C., Reeves, D., Alborz, A., et al. (1999). Staff characteristics, working conditions and outcomes amongst staff in services for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 12, 340–347.
Jenkins, R., Rose, J., & Lovell, C. (1997). Psychological well-being of staff working with people who have challenging behaviour. Journal of Intellectual Disability Research, 41, 502–511.
Jokinen, N. S., & Brown, R. I. (2005). Family quality of life from the perspective of older parents. Journal of Intellectual Disability Research, 49, 789–793.
Lin, C. H. (2003). The establishment of reliability and population norm of Taiwan SF-36. Master Thesis, Institute of Healthcare Management, China Medical College, Taiwan.
Lin, J. D., Lee, T. N., Yen, C. F., Loh, C. H., Hsu, S. W., Wu, J. L., et al. Job strain and determinants in staff working in institutions for people with intellectual disabilities in Taiwan: A test of the Job Demand-Control-Support model. Research in Developmental Disabilities (in press).
Lin, J. D., Loh, C. H., Choi, I. C., Yen, C. F., Hsu, S. W., Wu, J. L., et al. (2007). High outpatient visits among people with intellectual disabilities caring in a disability institution in Taipei: A 4-year survey. Research in Developmental Disabilities, 28, 84–93.
Lin, J. D., Yen, C. F., Loh, C. H., Hsu, S. W., Haung, H. C., Tang, C. C., et al. (2006). A cross-sectional study on the characteristics and determinants of emergency care utilization among people with intellectual disabilities in Taiwan. Research in Developmental Disabilities, 27, 657–667.
Loh, C. H., Lin, J. D., Choi, I. C., Yen, C. F., Shu, S. W., & Wu, J. L. (2007). Longitudinal analysis of inpatient care utilization among people with intellectual disabilities: 1999 to 2002. Journal of Intellectual Disability Research, 51, 101–108.
Male, D. B., & May, D. S. (1997). Burnout and workload in teachers of children with severe learning difficulties. British Journal of Learning Disabilities, 25, 117–121.
Ministry of the Interior (2006). The sixth national accreditation of disability welfare institutions in Taiwan. Department of Social Affair, MOI, No. 0940716447. Taipei, Taiwan.
Mitchell, G., & Hastings, R. P. (2001). Coping, burnout, and emotion in staff working in community services for people with challenging behaviors. American Journal on Mental Retardation, 106, 448–459.
Olsson, M. B., & Hwang, C. P. (2001). Depression in mothers and fathers of children with intellectual disability. Journal of Intellectual Disability Research, 45, 535–543.
Pearlin, L., Mullan, J., Semole, S., & Skaff, M. (1990). Caregiving and the stress process: An overview of concepts and their measures.
The Gerontologist, 30, 583–594.
Razza, N. J. (1993). Determinants of direct-care staff turnover in group homes for individuals with mental retardation. Mental Retardation, 31, 284–291.
Rice, D. M., & Rosen, M. (1991). Direct care staff: A neglected priority. Mental Retardation, 29, iiiiv.
Rose, D., Horne, S., Rose, J., & Hastings, R. P. (2004). Negative emotional reactions to challenging behaviour and staff burnout: Two replication studies. Journal of Applied Research in Intellectual Disabilities, 17, 219–223.
Rose, J. (1993). Stress and staff in residential settings: The move from hospital to the community. Mental Handicap Research, 6, 312–
332.
Rose, J. (1995). Stress and residential care staff: Towards an integration of research. Mental Handicap Research, 8, 220–236.
Rose, J. (1999). Stress and residential staff who work with people who have an intellectual disability: A factor analytic study. Journal of Intellectual Disability Research, 43, 268–278.
Rose, J., Jones, F., & Fletcher, B. (1998). Investigating the relationship between stress and worker behavior. Journal of Intellectual Disability Research, 42, 163–172.
Schalock, R., Brown, I., Brown, R. I., Cummins, R., Felce, D., Matikka, L., et al. (2002). Conceptualization, measurement, and application of quality of life for persons with intellectual disabilities: Report of an international panel of experts. Mental Retardation, 40, 457–
470.
Schofield, L., Murphy, B., Herrman, H. E., & Sing, B. (1997). Family caregiving: Measurement of emotional well-being and various aspects of the caregiving role. Psychological Medicine, 27, 647–657.
Schulz, R. (2000). Handbook on dementia caregiving: Evidence-based interventions for family caregivers. New York: Springer.
Schulz, R., & Beach, S. (1999). Caregivng as a risk factor for mortality: The caregiver health effects study. Journal of the American Medical Association, 282, 2215–2219.
Schulz, R., O’Brien, A., Bookwala, J., & Fleissner, K. (1995). Psychiatric and physical morbidity effects of dementia caregiving:
Prevalence, correlates, and causes. The Gerontologist, 35, 771–791.
Seoud, J., Nehme, C., Atallah, R., Zablita, C., Yeretzian, J., Levesque, L., Giroux, F., et al. (2007). The health of family caregivers of older impaired persons in Lebanon: An interview survey. International Journal of Nursing Studies, 44, 259–272.
Stenfert-Kroese, B., & Fleming, I. (1992). Staff’s attitudes and working conditions in community-based group homes of people with mental handicaps. Mental Handicap Research, 5, 82–91.
Summers, J. A., Poston, D. J., Turnbull, A. P., Marquis, J., Hoffman, L., Mannan, H., et al. (2005). Conceptualizing and measuring family quality of life. Journal of Intellectual Disability Research, 49, 777–783.
Tseng, H. M., Lu, J. F. R., & Tsai, Y. J. (2003). Assessment of health-related quality of life in Taiwan (II): Norming and validation of SF-36 Taiwan version. Taiwan Journal of Public Health, 22, 512–518.
Ware, J. E. (1993). SF-36 health survey: Manual and interpretation guide. Boston, MA: The Health Institute, New England Medical Center.
Ware, J. E., Kosinski, M., & Keller, S. D. (1994). SF-36 physical & mental health summary scale: A user’s manual. Boston, MA: The Health Institute, New England Medical Center.
